Analyzing credit balance accounts in the health care industry is an arduous and difficult task. A health care facility, such as a hospital, deals with hundreds of patients on a daily basis. For each service that a patient receives, a fee or multiple fees are charged for the service. The service fees are tracked through patient accounts. Each patient account has information concerning the service(s) rendered, the fee amount and any financial transactions made for the service. Payments for the service may be paid by Medicare, a health insurance payer or payers, the patient or a combination of them. Also, since the health care facility may make arrangements with Medicare and certain health care payers for discounts in the service fee, the account tracks these adjustments. As a result, for each date of service for a patient, an account is produced with fees, payments and discounts.
Due to the large number of these transactions occurring, errors or discrepancies may occur. To illustrate, an insurance company and the patient may both pay the entire amount for a service, creating a double payment for a service.
Correcting these errors and discrepancies is a long and arduous process. Typically, a group of adjusters will review each account to find errors and correct them. A manager of the group will divide the accounts among the adjusters and each adjuster will sequentially work through his/her accounts. To analyze an account, the adjuster pulls the patient account up on the health care facility's computer system by navigating through many screens. Each screen displays different information concerning the account. After reviewing the information on the screens, the adjuster may be able to resolve the error or may require additional information, such as an explanation of benefits (EOB). If additional information is required, the adjuster requests the information by filling out a form. After the adjuster receives the information, the adjuster will proceed in resolving the error or discrepancy. This approach takes a considerable amount of time. The adjuster must navigate through sometimes dozens of screens, make manual calculations, and request additional information in order to resolve the account.
Additionally, the manager/adjuster typically has no or little foreknowledge of the accounts prior to beginning the account analysis. As a result, the accounts may not be processed in an efficient manner. Difficult to resolve accounts may be given to inexperienced adjusters, instead of experienced adjusters. Accounts easily resolved dealing with large amounts of money may not be processed until after difficult accounts dealing with small amounts.
Also, reports must be made quarterly to Medicare regarding Medicare overpayments. These reports are derived from the patient credit balance accounts. As a result, errors in the patient credit balance accounts or patient credit balance accounts having Medicare overpayments not discovered leads to errors in the Medicare reports. Any errors in these reports can lead to civil and criminal penalties.
Accordingly, it is desirable to have better tools for managing, analyzing and resolving credit balance accounts.